Background: The incidence and severity of herpes zoster (HZ) appear increased in patients receiving tumor necrosis factor-α antagonists. Objective: To study the incidence and clinical features of HZ in 1,220 patients (4,206 patient-years) receiving either adalimumab, etanercept, infliximab, rituximab or ustekinumab. Results: Twenty-two HZ cases were identified [1.26% of total cohort; adalimumab: 11/1,546 patient-years, incidence rate (IR) 7.1; etanercept: 4/789 patient-years, IR 5.1; rituximab: 1/168 patient-years, IR 5.2; ustekinumab: 2/37 patient-years, IR 53.5; infliximab: 4/1,666 patient-years, IR 2.4]. The time to event varied widely (1.5– 108 months). Extensive HZ was reported in 45 and 32% of the cases, respectively. Persistent postzoster neuralgia (PHN; >6 months) was observed in 5/20 patients. Conclusions: The HZ incidence was 2.1-fold higher among patients over 60 years, compared with a reference population, although not statistically significant. Severe, multidermatomal HZ and persistent PHN were common.
Background: TNF-α antagonists may increase the risk of herpes zoster (HZ), as well as the duration and severity. Recently, the monoclonal antibody ustekinumab, blocking the p40 subunit of IL-12 and IL-23, has been introduced for treating moderate to severe plaque psoriasis. There are no PubMed reports of HZ occurring in people receiving ustekinumab treatment. Common HZ was reported in clinical trials. Observation: Two patients with severe psoriasis treated with ustekinumab developed severe contiguous multidermatomal HZ 1 and 9 months after treatment initiation. Discussion: The occurrence of HZ after the instauration of ustekinumab suggests a causal relationship. Indeed, the inhibition of the p40 subunit of IL-12 shifts the immune response towards a Th1 profile with diminished IFN-γ and TNF-α expression, decreasing the antiviral immune response. Conclusion: Ustekinumab is probably a risk factor for developing HZ. Anti-HZ vaccination prior to ustekinumab treatment should be considered.
Psoriasis affects about 2 to 3% of the caucasian population. It is a chronic inflammatory disease affecting predominantly the skin with the involvement of autoimmune mediated mechanisms. Typical pathogenic features include an increased renewal of epidermal keratinocytes, the enlargement of the germinating compartment, papillomatosis, altered epidermal differentiation, angiogenesis, lymphangiogenesis and inflammatory infiltration. Several types of psoriasis are distinguished and may be present simultaneously in some patients. Up to 20 candidate genes have been evidenced in psoriasis. Genetic variability explains different types of the disease and influences response to therapeutics. Furthermore, psoriasis is triggered or aggravated by infections, traumatisms, medications, stress, tobacco, alcohol and endocrine factors. Severe psoriasis is frequently associated with co-morbidities as obesity, diabetes, metabolic syndrome and cardiovascular diseases. For this reason, the similar pathogenic mechanisms of psoriasis and other IMID's (Immune Mediated Inflammatory Diseases) and the use of systemic treatments shared with other specialties, an updated vision of psoriasis for the internist is mandatory.
Background: Recurrences of herpes labialis (RHL) may be triggered by systemic factors, including stress, menses, and fever. Local stimuli, such as lip injury or sunlight exposure are also associated to RHL. Dental extraction has also been reported as triggering event. Case reports: Seven otherwise healthy patients are presented with severe and extensive RHL occurring about 2-3 days after dental extraction under local anaesthesia. Immunohistochemistry on smears and immunofluorescence on cell culture identified herpes simplex virus type I (HSV-I). Five patients reported more severe prodromal signs than usual. Although all the patients suffered from RHL, none had previously experienced RHL after dental care. Two patients required hospitalisation for intravenous acyclovir therapy, whereas the others were successfully treated with oral valaciclovir or acyclovir. Conclusion: Severe and extensive RHL can occur soon after dental extraction under local anaesthesia. Patients with a previous history of RHL seem to be at higher risk. It is not clear whether RHL is linked to the procedure itself, to the anaesthetic procedure or both. As the incidence is unknown, more studies are required to recommend prophylactic antiviral treatment in RHL patients who are undergoing extractions. Dentists should be aware of this potentially severe post-extraction complication.
Unexpected, significant increases in vitamin D levels were seen in melanoma patients during summer, suggesting non-adherence with photoprotective measures and reflecting a heliophilic behaviour. Vitamin D supplementation is recommended in melanoma patients during both winter and summer.
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